Glycemic control and cardiovascular disease: what's a doctor to do?

Awareness of cardiovascular risk among persons with type 2 diabetes: a qualitative study

PURPOSE

To describe the process of becoming aware of and acting on personal cardiovascular (CVD) risk in type 2 diabetes (T2D).

METHOD

A purposive sample of 14 persons living with T2D participated in semi-structured, open-ended, in-dept interviews. The interviews were analysed with grounded theory.

RESULT

The analysis identified the core category "Balancing emotions, integrating knowledge and understanding to achieve risk awareness and act on it." Five categories describe the movement from not being aware of the risk of cardiovascular disease (CVD) to becoming aware of this risk and taking action to reduce it. Persons with T2D need to transform their knowledge and experience of CVD risk and incorporate it in their individual situations. Emotional and existential experiences of CVD risk can lead to awareness about the severity of the condition and contribute to increased motivation for self-management. However, an overly high emotional response can be overwhelming and may result in insufficient self-management.

CONCLUSION

Persons with T2D seemed not to fully grasp their increased risk of CVD or recognize that self-management activities were aimed at reducing this risk. However, their awareness of CVD risk gradually increased as they came to understand the severity of T2D and became more emotionally and existentially engaged.

Continuous glycemia monitoring in perioperative period in patients undergoing total knee or hip arthroplasty: A protocol for a prospective observational study

In every surgical subspecialty surgical site infection (SSI) or implant infections, although occur seldom, pose a threat to patients' health. Risk factors of such states is diabetes mellitus (DM), considered one of the most widespread health-related problems of the 21st century. Orthopedists perform big joint replacements that usually concern older adults and therefore often deal with patients suffering from comorbidities. DM is frequently one of them and can furthermore often remain underdiagnosed. The other risk for complication is a rapid beginning of the rehabilitation which starts on the day following the surgery. To eliminate the debilitating impact of DM and hypoglycemia on surgical patients, we aim to investigate the relationship between the glycemia values and the postoperative outcomes in certain periods of time in patients undergoing orthopedic surgeries. Participants meeting inclusion criteria will have inserted a glycemia measuring device (Dexcom G5, Inc., San Diego, CA) in the periods of time. First time it will take place 14 days prior to the surgery and right after the surgery for the second time for the period of another 14 days. All patients will undergo standard total knee arthroplasty or total hip arthroplasty procedures. Patients will be assessed preoperatively and 14 days, 1, 3, 6, 12, and 24 months postoperatively. The assessment of the joint condition will consist of: patient-reported outcomes (The Knee injury and Osteoarthritis Outcome Score, Harris Hip Score, the Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]); assessment of potential SSI and cardiovascular complications (the Finnish Diabetes Risk Score [FINDRISC], the Systematic Coronary Risk Evaluation [SCORE]) and the clinical examination. To investigate the influence of orthopedic surgery (anesthesia) on glycemia and the significance and safety of early patients mobilization after the big joints surgeries. To investigate changes of glycemia in patients with normal glycemia metabolism, potentially protecting them from hypoglycemia during hospital stay and increasing their awareness of potential development of DM in the future. Additionally, this study will correlate perioperative glycemic levels with risk of cardiovascular events in one year follow-up, and its influence on SSI and implant complications.

Relationship between hyperglycaemia at admission and prognosis in patients with acute myocardial infarction: a retrospective cohort study

BACKGROUND

The optimal threshold of hyperglycaemia at admission for identifying high-risk individuals in patients with acute myocardial infarction (AMI) and its impact on clinical prognosis are still unclear.

METHODS

We retrospectively reviewed 2027 patients with AMI admitted from June 2001 to December 2012 in the 'Medical Information Mart for Intensive Care III' database. The significant cut-off values of admission blood glucose (Glucose_0) for predicting hospital mortality in patients with AMI with and without diabetes were obtained from the receiver operating characteristic (ROC) curve, then patients were assigned to hyperglycaemia and non-hyperglycaemia groups based on corresponding cut-off values. The primary endpoints were the hospital and 1-year mortality.

RESULTS

Among 2027 patients, death occurred in 311 patients (15.3%). According to the ROC curve, the significant cut-off values of Glucose_0 to predict hospital mortality were 224.5 and 139.5 mg/dL in patients with diabetes and without diabetes, respectively. The crude hospital and 1-year mortality of the hyperglycaemia subgroup were higher than the corresponding non-hyperglycaemia group (p< 0.01). After adjustment, regardless of the state of diabetes, hyperglycaemia at admission was related to significantly increased hospital mortality in patients with AMI. For patients with AMI without diabetes, hyperglycaemia at admission was positively correlated with the increase of 1-year mortality (HR, 1.47; 95% CI 1.18 to 1.82; p=0.001). Nevertheless, this trend disappeared in those with diabetes (HR, 1.35; 95% CI 0.93 to 1.95; p=0.113).

CONCLUSION

Hyperglycaemia at admission was an independent predictor for mortality during hospitalisation and at 1-year in patients with AMI, especially in patients without diabetes.

Hypermethylation Effects of Yiqihuoxue Decoction in Diabetic Atherosclerosis Using Genome-Wide DNA Methylation Analyses

Purpose

To investigate if a traditional Chinese medicine formulation, called “Yiqihuoxue” (YQHX), could improve diabetic atherosclerosis (DA) and explore potential mechanisms based on DNA methylation.

Methods

Apolipoprotein E-knockout mice were administered streptozotocin (50 mg/d, i.p.) for 5 days and fed a high-fat diet for 16 weeks. Mice were divided randomly into DA model, rosiglitazone, as well as low-, medium-, and high-dose YQHX groups. Ten healthy C57BL/6J mice were the control group. Serum levels of fasting insulin, blood glucose, homeostasis model-insulin resistance index (HOMA-IR), serum lipids, and inflammatory factors were analyzed after the final treatment. Aorta tissues were collected for staining (hematoxylin and eosin, and Oil red O). Genomic DNA was extracted for methyl-capture sequencing (MC-seq). Kyoto Encyclopedia of Genes and Genomes (KEGG) and Search Tool for the Retrieval of Interacting Genes/Proteins (STRING) databases were used to analyze differentially methylated genes. Pyrosequencing was used to verify MC-seq data.

Results

Low-dose and high-dose YQHX could reduce the HOMA-IR (P < 0.05). Low-dose YQHX reduced expression of total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C), TNF-α, andI L-6 in serum compared with that in the model group (P < 0.05). Medium-dose YQHX decoction inhibited the expression level of TNF-α (P < 0.05). High-dose YQHX decreased the expression level of IL-6 (P < 0.05). Staining also showed the anti-atherosclerosis effects of YQHX (P < 0.05). MC-seq revealed many abnormally hypermethylated and hypomethylated genes in DA mice compared with those in the control group. KEGG database analysis showed that the hypermethylated genes induced by YQHX treatment were related to pathways in cancer, Hippo signaling, and mitogen activated protein kinase. The network analysis suggested that the hypermethylated genes epidermal growth factor receptor(Egfr) and phosphoinositide-3-kinase regulatory subunit 1(Pik3r1) induced by YQHX treatment had important roles in DA. Pyrosequencing revealed that YQHX treatment increased methylation of AKT1, Nr1h3 and Fabp4 significantly (P < 0.05).

Conclusion

YQHX decoction had positive treatment effects against DA, because it could regulate aberrant hypomethylation of DNA.

Strong and Bitter Vegetables from Traditional Cultivars and Cropping Methods Improve the Health Status of Type 2 Diabetics: A Randomized Control Trial

Vegetables rich in bitter-tasting phytochemicals may exert enhanced beneficial effects against key factors associated with type two diabetes (T2D). This study investigates whether selected cultivars of bitter and strong-tasting (BST) Brassica and root vegetables exert greater health benefits on T2D patients compared to equivalent modern mild and sweet tasting (MST) vegetables. A 12-week randomized, controlled, parallel intervention study involved 92 T2D patients, who were allocated three different diets: (1) 500 g daily of bitter and strong-tasting (BST) vegetables; (2) 500 g daily of mild and sweet-tasting (MST) vegetables; (3) 120 g daily MST normal diet (control). Both vegetable diets contained root vegetables and cabbages selected based on sensory differences and content of phytochemicals. Prior to and after the study, all participants underwent an oral glucose tolerance test (OGTT), 24 h blood pressure measurements, DEXA scans, and fasted blood samples. Both diets high in vegetables significantly reduced the participants' BMI, total body fat mass, and HbA1c levels compared to control, but in the BST group, significant differences were also found regarding incremental area under the curve glucose 240 min (OGTT) and fasting glucose levels. A high daily intake of root vegetables and cabbages showed significant health improvements in both vegetable groups. BST vegetables had the greatest impact on insulin sensitivity, body fat mass, and blood pressure compared to control; moreover, they further improved glycemic control compared to MST vegetables.

Morphologic TPA (mTPA) and composite risk score for moderate carotid atherosclerotic plaque is strongly associated with HbA1c in diabetes cohort

BACKGROUND

This study examines the association between six types of carotid artery disease image-based phenotypes and HbA1c in diabetes patients. Six phenotypes (intima-media thickness measurements (cIMT (ave.), cIMT (max.), cIMT (min.)), bidirectional wall variability (cIMTV), morphology-based total plaque area (mTPA), and composite risk score (CRS)) were measured in an automated setting using AtheroEdge™ (AtheroPoint, CA, USA).

METHOD

Consecutive 199 patients (157 M, age: 68.96 ± 10.98 years), L/R common carotid artery (CCA; 398 US scans) who underwent a carotid ultrasound (L/R) were retrospectively analyzed using AtheroEdge™ system. Two operators (novice and experienced) manually calibrated all the US scans using AtheroEdge™. Logistic regression (LR) and Odds ratio (OR) was computed and phenotypes were ranked.

RESULTS

The baseline results showed 150 low-risk patients (HbA1c < 6.50 mg/dl) and 49 high-risk patients (HbA1c ≥ 6.50 mg/dl). The fasting blood sugar (FBS) was highly associated with HbA1c (P < 0.001). Except for cIMTV, all phenotypes showed an OR > 1.0 (P < 0.001) for left common carotid artery (LCCA), right carotid artery (RCCA), and mean of left and right common carotid artery (MCCA). After adjusting the FBS, the OR for mTPA showed a higher risk for LCCA, RCCA, and MCCA. The coefficient of correlation (CC) between phenotypes and HbA1c were strong and inter-CC between cIMT and mTPA/CRS was above 0.9 (P < 0.001). The statistical tests showed that phenotypes were significantly associated with diabetes (P-value<0.0001).

CONCLUSIONS

All phenotypes using AtheroEdge™, except cIMTV, showed a strong association with HbA1c. mTPA and CRS were equally strong phenotypes as cIMT. The CRS phenotype showed the strongest relationship to HbA1c.

The Genetic Link Between Diabetes and Atherosclerosis

Epidemiological studies have indicated that the risk of atherothrombotic coronary artery disease (CAD) is higher in patients with diabetes, but these results have not been consistently observed across clinical trials. To address this apparent discrepancy, we can apply the results of genome-wide association studies (GWAS) to provide a better understanding of the shared genetic architecture of diabetes and atherothrombotic CAD. For instance, a large GWAS has identified 16 novel loci that are associated with both diabetes and atherothrombotic CAD. These genetic variants may also be used to assess potential causal relationships reported in observational studies and clinical trials through Mendelian randomization analyses. For example, several Mendelian randomization analyses have shown that diabetes is associated with CAD independent of other risk factors (odds ratio [OR]: 1.63, 95% confidence interval [CI]: 1.23-2.07; P = 0.002). Furthermore, Mendelian randomization analyses can provide more insight into the perceived risk of diabetes among patients without diabetes receiving statin therapy. Here, genetically lower activity of HMG-CoA reductase (HMGCR) was associated with a modest increase in diabetes (OR per allele: 1.02, 95% CI: 1.00-1.05). These results highlight the biological mechanisms that link diabetes with the use of statins. In addition, this work illustrates the great potential value of genetic studies to clarify the mechanistic relationships among atherosclerotic vascular disease, dysglycemia, and diabetes. More research is needed to delineate and subsequently better understand the genetic links between diabetes and atherosclerosis.

Levels of Apolipoprotein A1, B100 and Lipoprotein (a) in Controlled and Uncontrolled Diabetic Patients and in Non-Diabetic Healthy People

INTRODUCTION

Diabetes Mellitus (DM) is always a multifactorial metabolic disorder having a wide range of abnormalities in carbohydrate, lipid and protein metabolism. Dyslipidemia is a natural process of DM causing abnormal variations of different lipoproteins and it is one of the significant risk factors for Cardiovascular Disorder (CVD). There is a need to closely evaluate newer approaches in case of DM because even if dyslipidemia is treated, there is always a risk of CVDs in DM patients because of the hyperglycemia itself. So, lipid abnormalities should be assessed aggressively and treated as part of diabetes care. Apolipoprotein B100 (Apo B100), Apolipoprotein A1 (Apo A1) and Lipoprotein (a) {Lp(a)} are newer markers which are always welcome and necessary as many of the reported cases with normal conventional lipid profile have developed cardiac events.

AIM

Study the correlation between glycemic control and the levels of Apo A1, Apo B100 and Lp(a).

MATERIALS AND METHODS

Total 56 patients of (DM) diagnosed on the basis of American Diabetic Association guidelines were recruited, out of which 28 were identified as uncontrolled-diabetic patients and remaining 28 as controlled-diabetics on the basis of Glycosylated HbA1c (HbA1c). The control group consisted of normal healthy 28 individuals. Apo B100, Apo A1 and Lp(a) along with traditional lipid profile, Fasting Blood Sugar (FBS) and HbA1c were estimated in all the subjects.

RESULTS

Apo B100/Apo A1 ratio and Lp(a) levels showed highly significant difference (p-value <0.001) between uncontrolled diabetics, controlled diabetics and healthy Controls. Apo B100/Apo A1 ratio and Lp(a) showed significant positive correlations with HbA1c (r= 0.494, p <0.0001) and with each other.

CONCLUSION

Apo B100/Apo A1 ratio and Lp(a) show a highly significant positive relationship with glucose tolerance of the patients as reflected in the HbA1c values. If proper glycemic control is maintained, the levels of Apo B100/Apo A1 ratio and Lp(a) can be controlled as reflected by the lower levels of these parameters observed in controlled diabetics in comparison to uncontrolled diabetics.

Correlation between hemoglobin A1c and serum lipid profile in Afghani patients with type 2 diabetes: hemoglobin A1c prognosticates dyslipidemia

BACKGROUND

Patients with type 2 diabetes (T2DM) have an increased prevalence of dyslipidemia, which contributes to their high risk of cardiovascular diseases (CVDs). This study is an attempt to determine the correlation between hemoglobin A1c (HbA1c) and serum lipid profile and to evaluate the importance of HbA1c as an indicator of dyslipidemia in Afghani patients with T2DM.

METHODS

A total of 401 Afghani patients with T2DM (men, 175; women, 226; mean age, 51.29 years) were included in this study. The whole blood and sera were analyzed for fasting blood sugar (FBS), HbA1c, total cholesterol (TC), triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C). Dyslipidemia was defined according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines. Diabetes was defined as per American Diabetes Association criteria. The correlation of FBS, HbA1c with lipid ratios and individual lipid indexes were analyzed. The statistical analysis was done by SPSS statistical package version 16.0.

RESULTS

The mean age ± standard deviation of male and female patients were 51.71 ± 11.70 and 50.97 ± 10.23 years respectively. There was a significant positive correlation between HbA1c, TC, TG, LDL-C and LDL-C/HDL-C ratio. The correlation between HbA1c and HDL-C was negative and was statistically nonsignificant. Furthermore, HbA1c was found to be a predictor of hypercholesterolemia, LDL-C and TG via a linear regression analysis. Patients with HbA1c value greater than 7.0% had significantly higher value of cholesterol, LDL-C, and LDL-C/HDL-C ratio compared with patients with an HbA1c value up to 7.0%.

CONCLUSIONS

Apart from a reliable glycemic index, HbA1c can also be used as a predictor of dyslipidemia and thus early diagnosis of dyslipidemia can be used as a preventive measure for the development of CVD in patients with T2DM.

Initial therapy, persistence and regimen change in a cohort of newly treated type 2 diabetes patients

AIMS

The aim was to describe the utilization of antidiabetic agents, in terms of persistence and regimen change, in the management of a cohort of newly treated type 2 diabetes patients and to investigate associated socio-demographic and treatment factors.

METHODS

A population-based retrospective cohort study was conducted using the national pharmacy claims database in Ireland. Subjects were analyzed for persistence and regimen change. Cox proportional hazards regression examined associations of socio-demographic and treatment factors on treatment patterns. Hazard ratios (HR) and 95% CIs are presented.

RESULTS

A total of 20947 subjects were identified in the study over a 2 year period. Most were initiated on metformin (76%) or sulphonylureas (22%) and 77% were persistent with therapy 12 months after initiation. The likelihood of non-persistence was significantly lower in the youngest (40-49 years) age groups (reference 60-69 years) (HR 1.62, 95% CI 1.42, 1.84) and those on sulphonylureas (HR 1.49, 95% CI 1.36, 1.64). The likelihood of receiving a regimen change was significantly lower in the older (80+ years) age groups (HR 0.63, 95% CI 0.56, 0.71), females (HR 0.91, 95% CI 0.86, 0.95), and those with pre-existing CVD (1 vs. 0 CVD medicines) (HR 0.82, 95% CI 0.74, 0.90), and higher in those on sulphonylureas (HR 1.83, 95% CI 1.73, 1.94).

CONCLUSIONS

Type of treatment, pre-existing CVD and demographic factors are shown to be associated with the observed treatment patterns. Guideline recommended agents were widely used on treatment initiation though a substantial minority were not initiated on the recommended first line agent. Use of guideline recommended agents was not as evident during treatment progression. Further optimization of initial and subsequent antidiabetic agent prescribing may be possible.

A review of cardiovascular outcomes in the treatment of people with type 2 diabetes

INTRODUCTION

Cardiovascular disease (CVD) is a common and serious complication of type 2 diabetes mellitus (T2DM) often linked to the increased morbidity and mortality associated with T2DM. Monitoring and treating risk factors for CVD are important elements of diabetes management. This review aims to examine CV risk in people with relatively early and mild diabetes who are at substantial risk of CVD; it considers the impact of insulin therapy on this risk by focusing on key studies in patients with diabetes.

METHODS

A literature search was carried out using PubMed to identify key publications, between 2008 and 2013, related to insulin and its possible effect on CVD. This review examines CV risk in diabetes and the impact of insulin therapy on this risk.

RESULTS

Studies have shown that treatment with insulin glargine is associated with marked improvement in the lipid profile of people with T2DM. Intensive insulin therapy has been shown to lower mortality rates in people with diabetes following acute myocardial infarction after 1 year. Retrospective data also indicate that insulin reduces the risk of CVD events, regardless of whether people had comorbidities known to increase CV risk. The prospective ORIGIN (Outcome Reduction with Initial Glargine Intervention) trial found that treatment with insulin glargine had a neutral effect with regard to CV outcomes in people with prediabetes or early diabetes, compared with standard care.

CONCLUSIONS

Other ongoing, large-scale studies of insulin therapy should provide further insights into whether or not insulin therapy can influence long-term CV outcomes.

Plasma triglycerides predict ten-years all-cause mortality in outpatients with type 2 diabetes mellitus: a longitudinal observational study

Background

Cardiovascular disease (CVD) is the leading cause of death in type 2 diabetes mellitus (T2DM). American Diabetes Association standards of care set a series of targets recommended for the CVD prevention: blood pressure, LDL and HDL cholesterol (LDL-C and HDL-C), triglycerides and HbA_1c goals. The aim of this study was to evaluate cardiovascular risk factors in a T2DM outpatient population in order to estimate their specific clinical value in predicting long-term overall mortality.

Methods

Our study population was composed of 1917 T2DM outpatients attending the hospital-based Diabetes Clinic of Ferrara for a mean follow-up period of 10 years; recorded information included personal, clinical and biochemical data, and pharmacological treatment.

Results

A Cox proportional hazard analysis was performed, pointing out as age (HR:1.08; IC95%: 1.06-1.11), sex (males: HR:1.97; IC95%: 1.26-3.07), mean triglycerides levels during follow-up (III vs I tertile: HR:1.87; IC95%: 1.12-3.12) and lipid-lowering treatment (HR:0.56; IC95%: 0.35-0.90) were significantly associated with all-cause mortality, independent of confounding factors such as mean values of LDL-C, HDL-C, HbA_1c, blood pressure, BMI, fasting glucose, and antihypertensive and antidiabetic treatment.

Conclusions

This finding suggests that more attention should be given to the management of cardiovascular risk in type 2 diabetic patients with high triglycerides levels.

Trajectories in glycemic control over time are associated with cognitive performance in elderly subjects with type 2 diabetes

Objective

To study the relationships of long-term trajectories of glycemic control with cognitive performance in cognitively normal elderly with type 2 diabetes (T2D).

Methods

Subjects (n = 835) pertain to a diabetes registry (DR) established in 1998 with an average of 18 HbA1c measurements per subject, permitting identification of distinctive trajectory groups of HbA1c and examining their association with cognitive function in five domains: episodic memory, semantic categorization, attention/working memory, executive function, and overall cognition. Analyses of covariance compared cognitive function among the trajectory groups adjusting for sociodemographic, cardiovascular, diabetes-related covariates and depression.

Results

Subjects averaged 72.8 years of age. Six trajectories of HbA1c were identified, characterized by HbA1c level at entry into the DR (Higher/Lower), and trend over time (Stable/Decreasing/Increasing). Both groups with a trajectory of decreasing HbA1c levels had high HbA1c levels at entry into the DR (9.2%, 10.7%), and high, though decreasing, HbA1c levels over time. They had the worst cognitive performance, particularly in overall cognition (p<0.02) and semantic categorization (p<0.01), followed by that of subjects whose HbA1c at entry into the DR was relatively high (7.2%, 7.8%) and increased over time. Subjects with stable HbA1c over time had the lowest HbA1c levels at entry (6.0%, 6.8%) and performed best in cognitive tests.

Conclusion

Glycemic control trajectories, which better reflect chronicity of T2D than a single HbA1c measurement, predict cognitive performance. A trajectory of stable HbA1c levels over time is associated with better cognitive function.

Clinical significance of glycated hemoglobin in the acute phase of ST elevation myocardial infarction

In population-based studies, including diabetic and nondiabetic cohorts, glycated hemoglobin A1c (HbA1c) has been reported as an independent predictor of all-cause and cardiovascular disease mortality. Data on the prognostic role of HbA1c in patients with acute myocardial infarction (MI) are not univocal since they stem from studies which mainly differ in patients' selection criteria, therapy (thrombolysis vs mechanical revascularization) and number consistency. The present review is focused on available evidence on the prognostic significance of HbA1c measured in the acute phase in patients with ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (PCI). We furthermore highlighted the role of HbA1c as a screening tool for glucose intolerance in patients with STEMI. According to available evidence, in contemporary cohorts of STEMI patients submitted to mechanical revascularization, HbA1c does not seem to be associated with short and long term mortality rates. However, HbA1c may represent a screening tool for glucose intolerance from the early phase on in STEMI patients. On a pragmatic ground, an HbA1c test has several advantages over fasting plasma glucose or an oral glucose tolerance test in an acute setting. The test can be performed in the non-fasting state and reflects average glucose concentration over the preceding 2-3 mo. We therefore proposed an algorithm based on pragmatic grounds which could be applied in STEMI patients without known diabetes in order to detect glucose intolerance abnormalities from the early phase. The main advantage of this algorithm is that it may help in tailoring the follow-up program, by helping in identifying patients at risk for the development of glucose intolerance after MI. Further validation of this algorithm in prospective studies may be required in the contemporary STEMI population to resolve some of these uncertainties around HbA1c screening cutoff points.